Wound Care Plan

Pressure Injury – Suspected Deep Tissue Injury

Last Updated
12 June 2025

Quick Overview

Reference ID Number: TWS-WCP-82

Categories

Scope of Practice (ScOP) Designation

Treatment Goals

Monitor the demarcation of the unstageable pressure injury

Aim of Dressing

Dry out the area that is an suspected deep tissue injury to minimise the area becoming gangrenous as the dead tissue demarcates.

Frequency of Dressing Change

Everyday

References

Shopping List

Page Table of Contents

    Product Selection Disclaimer:

    The wound care products being currently used are a suggestion ONLY. They do not take into account your patient's individual needs which you must assess. No funding from medical companies has been provided and wound care products are chosen on their merit and what is available on the NSW Health State Wound Care Contract. Where an exact brand name product is not available we suggest you review the alternative tab or use another wound care product from its category eg. Hydrofibre

    Photo Gallery

    Care Plans

    Unstageable Pressure Injury to the heels

    Where the heel has suffered a suspected deep tissue pressure injury. This is often seen as a deep rich bruise with a localised focal point

     Swipe 
    Step 1

    Paint area with betadine

    Paint the PI and surrounding area thoroughly. If the area is becoming wet you may need to apply a second coat after the first one has dried.
    Products Used
    Step 2

    Elevate the heels

    Elevate the heels to aid the area from further insult and to allow the maximum viable tissue to be saved during demarcation.
    Products Used
    Step 3

    Recheck

    Recheck area once per shift to monitor demarcation
    Products Used

    Unstageable Pressure Injury to the back

    Where the sacral/ scapula has suffered a suspected deep tissue pressure injury. This is often seen as a deep rich bruise with a localised focal point

     Swipe 
    Step 1

    Paint area with betadine

    Paint the PI and surrounding area thoroughly. If the area is becoming wet you may need to apply a second coat after the first one has dried.
    Products Used
    Step 2

    Offload affected area

    Offload weight from the affected area to minimise further insult and to allow the maximum viable tissue to be saved during demarcation.
    Products Used
    Step 3

    Recheck

    Recheck area once per shift to monitor demarcation
    Products Used